Bilomas: a new approach to the diagnosis and treatment

Intrahepatic biloma after intraoperative cholangiography

A woman in her 30s presented to the emergency department with a month-long history of postprandial epigastric pain radiating to her back. The diagnosis of cholecystolithiasis and suspected choledocholithiasis was made, and the patient underwent cholecystectomy with cholangiography using standard technique. The surgery was complicated by an intrahepatic bile duct injury attributed to high injection pressure during cholangiography. She developed an intrahepatic collection that was drained and confirmed the diagnosis of biloma. In this case report, we discuss a rare complication of intraoperative cholangiography during laparoscopic cholecystectomy and consider a way to prevent it.

Large biloma as the initial presentation of gallbladder perforation: a case report and literature review

Biloma is an encapsulated intra or extra-hepatic collection of bile after biliary tree trauma. Post-procedural and traumatic biliary damage are the most common etiologic causes. Gallbladder perforation due to acute cholecystitis rarely presents with biloma occurrence. We present a case of large extrahepatic biloma formation as a consequence of a perforated gallbladder.

Do not get stumped: multimodality imaging findings of early and late post-cholecystectomy complications

Cholecystectomy is the most performed intra-abdominal surgical procedure in the US, with 1.2 million performed annually, and is predominantly performed laparoscopically. Although largely safe, laparoscopic cholecystectomy results in higher rates of abdominal symptoms consisting of abdominal pain and dyspepsia, which may persist or recur, collectively known as post-cholecystectomy syndrome. This article aims to (1) provide an overview of post-cholecystectomy syndrome with an emphasis on biliary complications and emergent imaging findings, (2) illustrate the spectrum of imaging findings of early and late post-cholecystectomy complications, (3) enumerate the role of various imaging modalities in evaluating post-cholecystectomy complications and address the role of selective trans-catheter coil embolization in managing bile leaks, and (4) discuss pearls and pitfalls in imaging following cholecystectomy. While common first-line imaging modalities for post-cholecystectomy complications include CT and sonography, ERCP and MRCP can delineate the biliary tree with greater detail. Scintigraphy has a higher sensitivity and specificity than CT or sonography for diagnosing bile leak and may preclude the need for ERCP. Post-operative complications include biliary duct injury or leak, biliary obstruction, remnant gallbladder/cystic duct stones and inflammation, biliary dyskinesia, papillary stenosis, and vascular injury. Subtle cases resulting in lethal outcomes, such as hemorrhage from the gallbladder bed without major vessel injury, have also been described. Cases presented will include biliary complications such as post-cholecystectomy stump cholecystitis, nonbiliary complications such as subcapsular hematoma, and normal post-surgical findings such as oxidized regenerated cellulose. Post-operative biliary complications can cause significant morbidity and mortality, and thus familiarity with the expected post-surgical appearance of the gallbladder fossa and biliary tract, as well as understanding the spectrum of complications and associated multimodality imaging findings, are essential for emergency radiologists and those practicing in the acute care setting to direct appropriate patient management. Furthermore, many of the postoperative complications can be managed by noninvasive percutaneous interventional procedures, from drain placement to cystic artery and cystic duct stump embolization.

Intrahepatic subcapsular biloma after endoscopic retrograde cholangiopancreatography treated by endoscopic biliary drainage

Several major complications from endoscopic retrograde cholangiopancreatography (ERCP), including pancreatitis, cholangitis, and hemorrhage have been discussed in detail; however, a few uncommon but severe complications have been reported. We encountered an unusual case of post-ERCP intrahepatic subcapsular biloma. An 89-year-old woman with a 25-mm mass located at the hepatic hilum, suggestive of cholangiocarcinoma, underwent ERCP which demonstrated complete stricture of the common hepatic duct. Subsequently, two plastic stents were placed from the common bile duct to the right and left intrahepatic branches. On day 3, serum inflammatory markers were elevated and computed tomography revealed a large subcapsular fusiform fluid collection in the right liver, consistent with biloma. On day 6, the biloma ruptured and 500 ml of biliary ascites were removed. On day 8, endoscopic nasobiliary drainage via the right intrahepatic branch was performed because of recurrence of biliary ascites. After the procedure, 150 ml of bile was collected through the drain every day and no ascites recurred. We believe that minor injury to the right intrahepatic bile duct due to guidewire manipulation caused the biloma. Biloma may become apparent several days after ERCP, and endoscopic biliary drainage placement adjacent to the bile duct rupture site can stop bile leakage.

A giant and insidious subphrenic biloma formation due to gallbladder perforation mimicking biliary cystic tumor: A case report

Gallbladder perforation (GBP) represents a rare, but potentially life-threatening, complication of acute cholecystitis. GBP is subdivided into three categories whereas the development of biloma is extremely rare. The present case study reports on a 40-year-old man with a 10-year history of calculus cholecystitis, who was referred to The First Affiliated Hospital of Nanjing Medical University (Nanjing, China) for the surgical treatment of an emerging massive hepatic entity with insidious symptoms and normal laboratory tests. A preoperative imaging study demonstrated the collection with internal septations and mural nodules, but no visible communication with the biliary system. Given the suspected biliary cystic tumor, a laparotomy was performed and the lumen was scattered with papillae. An intraoperative frozen section examination illustrated a simple hepatic cyst. Biochemical analysis of the collection and histopathology of the gallbladder and capsule substantiated the diagnosis of biloma formation due to GBP. The purpose of the present case report was to demonstrate how a pinhole-sized perforation with extravasation of unconcentrated bile from the gallbladder may result in insidious clinical presentation and an undetected leak site. According to the clinicopathological characteristics and composition, formation of biloma should be classified as type IV GBP. To differentiate bilomas with intracystic septations and mural nodules from BCTs is difficult via a preoperative examination, and the definitive diagnosis should be based on a histological examination. Laparotomy with frozen section examination may be the optimal approach in such a case.

Etiology, Diagnosis, and Management of Bilomas: A Current Update

A biloma is a well-demarcated collection of bile outside the biliary tree. Traumatic and iatrogenic injuries, most commonly secondary to cholecystectomy, are the usual causes. Although bilomas are relatively uncommon, this pathologic entity may lead to significant morbidity and mortality if not promptly diagnosed and properly managed. As clinical signs and symptoms of bilomas are often nonspecific and laboratory values may be unremarkable, imaging modalities including ultrasound, computed tomography, magnetic resonance imaging, and hepatobiliary cholescintigraphy play a crucial role in the diagnosis of this condition. It is paramount that interventional radiologists not only be well versed in the management of bilomas but also be knowledgeable in the diagnosis as well as key imaging findings that dictate the interventional management. The purpose of this article is to review the etiology, pathophysiology, and clinical presentation of bilomas to primarily focus on the relevant multimodal imaging findings and the minimally invasive management options.

Hepatic subcapsular biloma: a rare complication of laparoscopic cholecystectomy

The development of an intra-abdominal bile collection (biloma) is an infrequent complication of laparoscopic cholecystectomy (LC). These bilomas develop in the subhepatic space most often secondary to iatrogenic injury of the extrahepatic ducts. We present a case of hepatic subcapsular biloma following LC and we discuss its etiology and management. Early diagnosis is crucial and percutaneous drainage under CT guidance should be employed to resolve this complication.

Posttraumatic Intrahepatic Bilioma

Blunt injury abdomen causing biliary injury is rare in children. Collection of bile within or outside the liver after biliary injury is called bilioma. CT scan images of late presenting intra-hepatic bilioma are shown.

A novel endoscopic treatment of major bile duct leak

INTRODUCTION

Bile leak is a serious complication of hepatobiliary surgery. The incidence has remained the same over the last decade despite significant improvement in the results of liver surgery.

PRESENTATION OF CASE

A 21-year-old man was a passenger in a motor vehicle and sustained a blunt abdominal trauma in a high-speed collision leading to major liver laceration. He had right lobe hepatectomy complicated by major bile leak. He was not fit for further surgery and he, therefore, had ERCP and obliteration of the leaking bile duct using a combination of metallic coil and N-butyl cyanoacrylate.

DISCUSSION

Endoscopic therapy has become the modality of choice in the treatment of biliary tract injuries. Different modalities of management of persistent bile leak such as sphincterotomy, plastic biliary stents, and nasobiliary drainage have been described. Obliteration of bile duct leak using N-butyl cyanoacrylate and coil embolization has been described but most of these reports used the percutaneous transhepatic approach.

CONCLUSION

In this paper, we describe the second reported case in English literature of a novel endoscopic technique using a combination of metallic coil embolization and N-butyl cyanoacrylate in a patient with major bile leak who was not a candidate for surgery as well as a third report of the late complication of coil migration to the common bile duct.

Chemoembolization with drug-eluting beads complicated by intrahepatic biloma

Chemoembolization with drug-eluting beads is a type of locoregional therapy currently being used for the treatment of hepatocellular carcinoma and metastatic disease to the liver. This treatment has proven effectiveness in controlling tumor growth, extending survival time, and improving quality of life. Chemoembolization with drug-eluting beads have been shown to be safe, but like any other invasive procedure, can have associated complications. The authors present a case of intrahepatic biloma formation occurring as a result of treatment with drug-eluting beads.

Spontaneous biloma managed with endoscopic retrograde cholangiopancreatography and percutaneous drainage: a case report

Introduction

Spontaneous biloma formation is a very rare condition, which mandates immediate treatment.

Case presentation

An 80-year-old Caucasian man was referred to our department with a diagnosis of intra-abdominal collection located in his right upper quadrant. Further radiological examination demonstrated multiple calculi in his gallbladder and common bile duct. Our patient underwent endoscopic retrograde cholangiopancreatography and the stones in the common bile duct were extracted. Percutaneous drainage of the abdominal collection revealed a spontaneous biloma formation. Continuous drainage of bile persisted for one week, so endoscopic retrograde cholangiopancreatography was repeated and a 10Fr stent was placed; subsequently the biliary leak ceased and our patient was discharged. A control abdominal computed tomography did not show any residual fluid collection.

Conclusion

Spontaneous biloma formation is a very rare incidence; awareness is necessary for prompt recognition and treatment.

Biloma: An unusual complication in a patient with pancreatic cancer

The term biloma describes an encapsulated collection of bile within the abdomen, usually secondary to bile duct disruption. The commonest causes reported in the literature are iatrogenic (secondary to hepatobiliary surgery), trauma or complications due to choledocholithiasis. A few cases have been reported as complications of cholangiocarcinoma or acute cholecystitis. We report the case of a 64-year-old man initially diagnosed with a non-obstructive malignancy of the pancreas, who developed a spontaneous intrahepatic biloma 8 mo later. This was identified following a 1-wk history of fever, rigors and icterus. The biloma was identified on computed tomography and subsequently drained under ultrasound guidance. Forty-eight hours later, a stent was inserted endoscopically into his common bile duct and he made an uneventful in-hospital recovery. We believe this is the first documented case of spontaneous intrahepatic biloma to occur secondary to pancreatic malignancy.

Spontaneous idiopathic subcapsular biloma

Spontaneous biloma is an uncommon entity. We report a case of subcapsular biloma in an elderly patient with a nonobstructed biliary channel, without prior history of surgery, instrumentation, or trauma. Computed tomography (CT) and magnetic resonance imaging are described. We believe that this is the first reported case of spontaneous subcapsular biloma of idiopathic origin.

A case of infected biloma due to spontaneous intrahepatic biliary rupture

A "biloma" is a loculated collection of bile located outside of the biliary tree. It can be caused by traumatic, iatrogenic or spontaneous rupture of the biliary tree. Prior reports have documented an association of biloma with abdominal trauma, surgery and other primary causes, but spontaneous bile leakage has rarely been reported. A spontaneous infected biloma, without any underlying disease, is a very rare finding. We recently diagnosed a spontaneous infected biloma by abdominal computed tomography and sonographically guided percutaneous aspiration. The patient was successfully managed with percutaneous drainage and intravenous antibiotics. We report here a case of infected biloma caused by spontaneous rupture of the intrahepatic duct, and review the relevant medical literature.

A single center experience in minimally invasive treatment of postcholecystectomy bile leak, complicated with biloma formation

BACKGROUND

Bilomas are localized collections of bile occurring usually post-operatively from an injured cystic or bile duct. Our study aims to evaluate the efficacy of minimal access endoscopic and percutaneous modalities in treating symptomatic bile leak and biloma formation.

PATIENTS AND METHODS

Sixteen patients with biloma after open or laparoscopic cholecystectomy underwent assessment of the site and extent of the bile leak via endoscopic retrograde cholangiography (ERC). Endoscopic sphincterotomy was performed in all patients who were managed non-operatively, any retained duct stones were removed, and an endoprosthesis was inserted in a selected basis. Percutaneous drainage of the bile collection, under ultrasound or computed tomography guidance, followed ERC.

RESULTS

ERC supplemented by computed tomography or ultrasound guided percutaneous biloma drainage was successful in 15 patients. One patient having major ductal injury was treated surgically. Thirteen patients had leakage from the cystic duct, one from the right hepatic duct, and one from an aberrant right hepatic duct. Bile duct stones were removed from seven patients an endoprosthesis was inserted in six and a nasobilary catheter in one. Bilomas resolved and bile leakage was treated successfully in all 15 patients with no further complications.

CONCLUSION

ERC accurately diagnoses the cause of postcholecystectomy bile leakage and biloma formation. Furthermore, endoscopic sphincterotomy and selective stent insertion in coordination with percutaneous drainage procedures represents in the majority of cases the corner stone of a definitive treatment.

A large biloma causing gastric outlet obstruction after a percutaneous liver biopsy

Biloma formation has not been reported to occur after a routine percutaneous liver biopsy. It is an uncommon yet well known complication of laparoscopic cholecystectomy. We report the development of a biloma within 1 week after a liver biopsy with a Jamshidi needle in a non-cirrhotic patient with hepatitis C. The biloma was large and caused a dramatic alteration of the hepatic contour and displaced the liver medially, resulting in gastric outlet obstruction. The biloma was treated successfully with percutaneous drainage. We believe this to be the first report of a large biloma causing gastric outlet obstruction as a complication of percutaneous liver biopsy.

Spontaneous biloma as a complication of small cell lung cancer

Biloma is an extraductular collection of bile within a defined capsular space. Prior reports have documented an association between biloma and abdominal trauma, and between biloma and iatrogenic injury resulting from abdominal surgery, percutaneous catheter drainage, or transhepatic cholangiogram. To our knowledge, bilomas have not previously been associated with lung cancer. We report a case of spontaneous biloma that developed as a complication of small cell lung cancer.

Bile leakage following laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is now the treatment of choice for gallstones, but there has been concern that bile leakage with LC is more frequent than after open cholecystectomy (OC). We have analyzed our experience of this complication with regard to both its incidence and management. From a consecutive series of 500 LC, in which both operative cholangiography and drainage of the gallbladder bed were routine, bile leakage was identified in ten patients (2%). There was no bile duct injury. Nine of the ten patients presented with bile in the drain within 24 h of operation and one patient presented 1 week after operation with a subphrenic collection. Of the ten patients, five settled spontaneously. Of the five remaining patients, two needed laparotomy--one for a subphrenic collection not responding to percutaneous drainage and one for biliary peritonitis. One patient was treated by relaparoscopy and suture of a duct of Luschka and one patient had successful percutaneous drainage of an infected collection; the fifth patient who presented with a late subphrenic collection of bile was shown at endoscopic retrograde cholangiopancreatography (ERCP) to have a cystic duct stump leak and was treated with an endoscopic stent. Bile leakage is seen more frequently after LC than OC for reasons that are currently unclear. We believe that the use of routine gallbladder bed drainage is justified for this reason alone. The majority of bile leaks settle either spontaneously or with minimally invasive intervention.

Bile duct disruption after laparoscopic cholecystectomy

The reported prevalence of biliary tract disruption following laparoscopic cholecystectomy has ranged from 0% to 7% in early reports. We have reviewed the first 823 laparoscopic cholecystectomies performed at our institution and found 13 symptomatic biliary complications necessitating further therapy (prevalence 1.6%). This finding represents a decrease from the 2.7% prevalence found in our earlier series. The incidence of biliary complications will likely continue to vary depending on patient selection, operator experience, and new developments in laparoscopic technique. Bile duct injury and bile leaks are often difficult to diagnose but must be strongly considered in postoperative patients with abdominal pain, fever, jaundice, or continued bilious drainage from a surgical drain. Whereas computed tomography (CT) and sonography are sensitive in detecting perihepatic or free peritoneal fluid collections, they are nonspecific and definitive diagnosis of biliary tract injury requires hepatobiliary scintigraphy, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), or percutaneous aspiration. Disruption of the biliary tree has commonly been treated with reoperation or percutaneous drainage. More recently, endoscopic management has shown encouraging results for bile leaks and strictures in small series.

Bile leakage after biliary tract surgery. A laparoscopic perspective

The incidence of bile leaks has increased with laparoscopic cholecystectomy as compared with open cholecystectomy. Minor bile leaks are not infrequent but are clinically insignificant; of the major bile leaks the most common sequela is the biloma, the most serious, bile peritonitis. Early symptoms may be very subtle; all untoward symptoms should be investigated with a HIDA scan to rule out bile leakage. Positive HIDA scans should be followed with endoscopic retrograde cholangiography (ERC) or percutaneous transhepatic cholangiography (PTC). Management of the leakage depends on identification of its source. Prompt identification of ductal injuries permits earlier effective treatment and consequently less morbidity and/or mortality.

Percutaneous abscess and fluid drainage: a critical review

Pertinent radiologic and surgical literature regarding abscess drainage was reviewed. Noted is the heterogeneity of disorders categorized as abscesses, and the variety of therapeutic approaches presently available. Specific abscesses are discussed based on body location and/or associated organ system.